A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
Document the infiltration.
Stop the infusion.
Elevate the arm.
Apply a warm compress.
The Correct Answer is B
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.
Correct Answer is A
Explanation
Choice A reason:
Among the options listed, cheese is the food that is contraindicated with MAOI use. Cheese is high in tyramine, and consuming it while taking MAOIs can lead to a potentially life-threatening hypertensive crisis.
An MAOI (Monoamine Oxidase Inhibitor) is a type of medication used to treat depression, anxiety, and other psychiatric disorders. When taking MAOIs, it is important to avoid certain foods that contain high levels of tyramine, as it can lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Choice B reason:
Potatoes: Potatoes are not contraindicated with MAOI use. They do not contain significant levels of tyramine.
Choice C reason:
Grapefruit: Grapefruit is not contraindicated with MAOI use. However, it can interact with certain medications, so it's always a good idea to check with the healthcare provider or pharmacist about specific medication interactions.
Choice D reason:
D. Eggs: Eggs are not contraindicated with MAOI use. Like potatoes, they do not contain significant levels of tyramine.
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